How to address difficulty of swallowing (dysphagia)?

Management of Dysphagia (Difficulty Swallowing)

The management of dysphagia requires a comprehensive evaluation followed by targeted interventions including dietary modifications, postural techniques, swallowing exercises, and appropriate referrals to specialists, with early involvement of a Speech-Language Pathologist being critical for optimal outcomes. 1, 2

Assessment and Diagnosis

• Dysphagia affects up to 22% of adults in primary care settings, with adults over 65 accounting for up to two-thirds of all cases 1, 3
• Initial evaluation should include assessment of:
  • Oral function: lip closure, saliva accumulation, tongue strength/mobility, chewing capacity
  • Pharyngeal function: palatal movement, cough quality/strength, voice quality 3
• Structured screening tools like EAT-10 offer high discriminatory capacity for identifying patients with aspiration (sensitivity 86%, specificity 76%) 3
• Bedside swallowing tests like the Volume-Viscosity Swallow Test (V-VST) have 92% sensitivity and 80% specificity compared to videofluoroscopy 3
• Important to recognize that dysphagia may be asymptomatic - in one study, 55% of patients who aspirated had silent aspiration with absent protective cough reflex 1, 3

Instrumental Assessment

• Videofluoroscopic Swallowing Study (VFSS) is the most common instrumental assessment for dysphagia 1
  • Allows visualization of bolus manipulation, tongue movement, hyoid/laryngeal elevation, pharyngeal constriction, and aspiration 3
  • Helps determine specific swallowing impairments and effectiveness of intervention strategies 1
• Fiberoptic Endoscopic Evaluation of Swallowing (FEES) can be performed at bedside and allows direct visualization of pharyngeal and laryngeal structures before and after swallowing 1
• For esophageal dysphagia, barium esophagogram can detect structural and functional abnormalities with 96% sensitivity for esophageal cancer diagnosis 3

Management Strategies

Compensatory Approaches

• Oral care interventions can reduce the risk of pneumonia and fatal pneumonia in non-ventilated patients with dysphagia, though evidence has high risk of bias 1
• Postural techniques:
  • Chin-down (chin-to-chest) posture is beneficial in most cases as it protects airways by opening the valleculae and preventing laryngeal penetration 1
  • Head rotation is indicated for hypertonicity or premature upper esophageal sphincter closure 1
  • Head extension may help when lingual pump is absent, but only if safe transit is ensured 1
• Dietary modifications:
  • Adapt food textures (soft, semi-solid, semi-liquid) to compensate for poor oral preparation and ease pharyngeal transport 1
  • Use thicker liquids for delayed swallowing to reduce aspiration risk 1
  • Follow the International Dysphagia Diet Standardisation Initiative (IDDSI) framework for standardized food and liquid texture modifications 1
  • For patients with fatigue, recommend fractionating meals into smaller, more frequent portions with high-calorie content 1

Rehabilitative Approaches

• Speech-Language Pathologists can provide:
  • Swallowing maneuvers like effortful swallow to improve pharyngeal pressure generation 1
  • Exercises to strengthen oral and pharyngeal muscles 4, 5
  • Training in specific swallowing techniques 4
• For functional dysphagia, cognitive-behavioral approaches may be beneficial:
  • Identify and challenge beliefs like "food will stick in my throat" or "I will choke" 1
  • Address maladaptive behaviors such as avoidance of certain foods or eating in isolation 1
  • Recommend positive self-statements during swallowing 1

Special Considerations

• In end-of-life care, careful hand feeding is preferred over feeding tubes, as tubes do not improve outcomes and may increase discomfort 2
• For patients with ALS and dysphagia:
  • Fractionate and enrich meals with energy or deficient nutrients 1
  • Adapt food texture based on instrumental swallowing assessment 1
  • Use chin-tuck posture to protect airways during swallowing 1
• Patients with botulinum toxin injections should be monitored for dysphagia as a potential adverse effect, especially those with pre-existing neuromuscular disorders 6
• Monitor for dehydration in dysphagic patients, as limited fluid intake can lead to electrolyte imbalances and increased morbidity/mortality 7

When to Refer

• Early involvement of a Speech-Language Pathologist is critical for thorough assessment and management 2
• Indications for immediate endoscopy include:
  • Inability to tolerate sufficient liquid diet leading to dehydration
  • Profound weight loss
  • Foreign body impaction with inability to tolerate secretions 3
• Interprofessional team approach including palliative care specialists, geriatricians, SLPs, and nursing staff improves outcomes 2